Africa’s population is on the rise. In 2021, Africa’s annual population growth was 2.45%, with estimates suggesting that the growth rate will be above 2% for the next 20 years. Based on data from Ghana’s last census the country’s population growth rate is 2.1%, slightly lower than the continent average. The result of this high growth rate is that there is a bulge in the youthful population and a gradual increase in the percentage of our population over the age of 60 years.
In 2020, the percentage of Ghana’s population above the age of 60-years was 5.33% with a population growth rate of 4.78%. An indication that this segment of the population is growing at a much faster rate than the general population. Unfortunately, as humans age, the number of chronic diseases that people live with increases. Data available from the United States Centers for Disease Control and Prevention indicates that approximately 85% of adults above the age of 60-years have at least one chronic health condition, and 60% have at least two. Meaning this proportion of the population account for a higher percentage of our countries health expenditure.
A look at Ghana’s current parliament shows that the average age of members is 49 years compared with 48.2 years for the previous parliament. This is over double the median age of the Ghanaian population which stood at 20.51 years in 2021. Based on the correlation between age and chronic disease burden, it is expected that members of Ghana’s political class will have a disproportionately higher number of chronic diseases compared to the general population. This should have been enough motivation for them to prioritise the quality of our health system. Unfortunately, although cloaked with the power, they have failed to achieve this.
It has been argued that this is because of the tendency of political players to access healthcare beyond our shores when need be. Though this smacks of cognitive dissonance it is not surprising. It is not because all chronic diseases when diagnosed have a prognosis and eventual outcome depending on the concordance of all that’s involved in the care process. These outcomes generally are better for countries with a Gross Domestic Product (GDP) of USD$4000 or more and with a health expenditure per capita of $88 and above. With our country not meeting either of these benchmarks, our decision-makers tend to be attracted to other countries as private patients. This phenomenon is termed medical tourism. Medical tourism can be defined as the process of travelling outside one’s country of residence to receive medical care. Often, this travel is for treatments that are unavailable in the country of origin.
However, in recent times, travel has been necessitated because of a lack of trust in the quality of healthcare being provided locally. This can be seen from the number of politically exposed mothers who opt to have their children in other countries rather than using health facilities funded with taxpayers money for which as custodians of political power, they have oversight responsibility. When such travels comes to light, the citizenry is thrown into heated debates with some suggesting the outright banning of such travels and others justifying.
The point is, an outright ban on medical tourism is not feasible though it is appealing from the political propaganda standpoint. It is not because for most Ghanaians, in the executive, legislature, senior-level civil service and parastatal organisations, foreign travel is part of their activities. This means, in an emergency while abroad they are expected to access healthcare at the expense of the taxpayer or their organisations. The potential for the blurring of the definition of an emergency means any such ban may not be enforceable. This is the case in Nigeria where the law exists but is ineffective.
We are of the view therefore that an honest conversation is required about our health system, the quality of care provided, healthcare access and the options for improvement. Any such conversation should look at the major drivers of medical tourism. Primary among these are the investments our governments make in the health sector. Ghana’s health expenditure per capita of USD$78 (2020) of which 38.9% (USD$30.3) is government contribution does not provide any fiscal space after salaries and emoluments are paid and provide little opportunity for any structured investment in health.
This will have to increase to USD$88 at a minimum with the extra funding coming from the government. Our view is that consumables like alcohol, cigarettes and sugar which have been identified as risk factors for chronic diseases can be specially levied with the revenue generated used to increase the government’s contribution to health expenditure. We also need to ensure the efficient utilisation of our health investments. We cannot continue to pump money into infrastructures we fail to complete, train fewer health professionals than we need to run our health systems, fail to employ health professionals we have trained or fail to ensure their upskilling.
All these are ingredients that go into improving a health system and the quality of care that the system provides. Any such improvements will result in an improvement in the confidence citizens have in the system and could potentially turn the country into a destination for, rather than a source of medical tourists. It is only when this occurs that the politically exposed classes will begin to use the system too. The point is we cannot continue to shout ourselves hoarse and expect these actors to alter their health-seeking behaviours when thanks to their positions they have health tourism as an option.
We must take cognisance that when these privileged Ghanaians travel abroad to seek healthcare, the taxpayer pays disproportionately more than what citizens of the destination countries are paying. This is because they are classified as private patients who are not covered by any health insurance. This high cost of care paid goes to improve the health expenditure per capita of the destination country and allows for further improvement in the quality of care for their citizens. Though we do not have reliable data on outbound expenditure on health for Ghana, we are aware that in 2016, Africans spent over USD$6 billion on outbound treatment. This equates to an average of USD$111 million annually per country in 2016 and was estimated to have been increasing by 6.3% yearly.
Sadly, these funds are being spent on a selected few with little to show for by way of value for money as their life expectancies are not altered significantly due to the treatment. We are of this view because the average life expectancy at 60 years in Ghana was 15.81 years in 2020, meaning a majority of those who reach this age are expected to live to approximately 75 years. This is hardly achieved by those who have passed away following medical tourism. This begs the question of why the practise should continue.
The irony also is that most who seek healthcare abroad end up dealing with the harsh reality of our healthcare system in their last days of life. This occurs either because they are too frail to undertake further journeys abroad or they develop complications that require emergency care and succumb in the process. For us, this is the biggest motivation why this should be fixed. We are not naïve though to think without purposeful planning and citizen agitation much will change. We come to this conclusion based on the proverbial saying that “turkeys don’t vote for Christmas.” Making it unlikely that our politicians will move to alter this without being coerced.
We will end by reminding readers that not long ago, most of the Kings, Sultans and Royals in Kingdoms that are medical tourism destinations today were tourists themselves too. They were able to reverse the trend and turn a financial drain into a national income source when opted to plan, develop, consistently maintained and upskill their health human resources. This happened due to the exercising of political will and a demonstration of visionary leadership. More importantly, it gave them the option to pass away in dignity in a place where they called home. Our politicians must realise that as it stands they cannot be guaranteed dignity in the dying process irrespective of how much they spend abroad to stay alive. This for us is a subject for sombre pondering. Rather than continuing this unproductive venture, Ghana must emulate these new destinations and tap into the over USD$6 billion that is spirited from the African continent annually.
Kwame Sarpong Asiedu (PhD) is a pharmacist by profession and CDD-Ghana’s Democracy & Development (D&D) Fellow in Public Health.
